What’s Up, Doc? How can I avoid shingles?

Thursday

Jun 21, 2007 at 12:01 AMJun 21, 2007 at 9:22 PM

Health columnist Dr. Jeff Hersh on shingles.

Dr. Jeff Hersh

Q: My 75-year-old friend has been suffering with a terrible case of shingles for a few weeks now. I am 79 and really do not want to go through what she has had to go through. Is there anything I can do to prevent getting shingles?

A: For those of you who have read my column before, you know I strongly believe that an ounce of prevention is worth a pound of cure. Although there is no way I know of to 100 percent prevent getting shingles, there is a vaccine that can significantly reduce the risk of getting it.

Shingles (herpes zoster, in medical jargon) is due to a reactivation of the chickenpox virus (Varicella). Although many children today are getting the chickenpox vaccine -- and are not getting chickenpox -- most adults had chickenpox when they were kids. Varicella may not leave our bodies completely but instead may lie dormant ("sleep") in the sensory nerve roots (ganglia), and for reasons we do not entirely understand can become active again. When this happens, it causes a reaction in the skin innervated by the nerve root the virus was sleeping in, and this characteristic of the rash (being in a section of skin corresponding to a single nerve root) is one of the things that can help your doctor diagnose this condition.

The rash from shingles starts as a vesicular/blister rash and evolves into pustules (or sometimes hemorrhagic lesions) over several days. The lesions usually crust over within a week or two. The reactivation of the virus affects the skin’s sensory nerves and can cause pain, burning, numbness, tingling or other symptoms. In fact, the sensory symptoms often precede the eruption of the rash by a few days and can be quite severe in some patients.

Shingles is very common. It is estimated that between 10 and 20 percent of the population will get shingles in their lifetime. Of the 300,000 to 500,000 cases that occur annually in the U.S., a disproportionate amount of these affect the elderly. This is thought to be because of waning immunity against the virus as we age. More than 80 percent of cases of shingles are in adults, and about a third of all cases are in people older than 55. Shingles is more common in people with weakened immune symptoms (including people with HIV or those on immune suppressive medications such as people who have had organ transplants, as well as people with other diseases that suppress the immune system), and will cause complications more frequently in these patients.

There many possible complications of shingles, including eye involvement (if the nerve root the virus laid dormant in involved the eye), systemic complications (including meningitis or encephalitis, although these are thankfully rare) and others, but the most common complication of shingles is post-herpetic neuralgia (PHN), and this is what I will focus my discussion on today.

PHN is persistent symptoms for more than 30 days after getting shingles. The symptoms are the sensory symptoms similar to the acute phase of shingles, including pain, numbness, tingling, burning or other sensory symptoms; in simple terms, it means the terrible symptoms from shingles become a chronic problem. PHN develops in 10 to 15 percent of people who get shingles, again disproportionately affecting the elderly, and can severely affect the quality of the patient’s life.

From this discussion, it should be clear that shingles and its possible sequelae, specifically PHN, are conditions that would be nice to avoid.

Staying active, getting regular and adequate sleep and eating well can help keep your immune system strong and hence may minimize the chances of getting shingles. One article I found noted that practicing Tai Chi might also minimize the risk of getting shingles. These things are generally good for your health, and so are good ideas anyway.

The idea behind giving a vaccine to reduce the risk of getting shingles is that waning immunity may be a key factor as to why the Varicella virus reactivates in the first place. I found several studies discussing the efficacy of the zoster vaccine, the largest from a New England Journal of Medicine article in 2005.

This study looked at more than 38,000 people older than 60 who were randomized to either the zoster vaccine or a placebo shot. The only bad affects significantly noted from the vaccine were local reactions at the site of the injection (including rashes), and these were, in general, mild. The vaccine proved to be very useful to decrease the incidence of shingles. The rate of 11 cases per 1,000 person-years in the placebo group was decreased by more than 50 percent to 5.4 cases per 1,000 person-years in the treatment group. For those who did get shingles, the duration of illness was slightly shorter and milder. Overall, PHN was decreased by 66 percent!

Based at least partly on these results, in October 2006, the Centers for Disease Control (CDC) recommended that all adults older than 60 who are eligible, whether or not they have had shingles or even the chicken pox before, get the zoster vaccination.

From the data I have seen, I believe the CDC’s recommendation to be a solid one, and I would recommend consideration of the zoster vaccine to all people older than 60. The vaccine is a live attenuated vaccine (it is made from real virus that has been modified so as not to cause disease), and therefore may not be appropriate for patients with certain medical conditions. So check with your doctor to see if this vaccine is appropriate for you. If you do get shingles, there are medications that can help reduce the chances of your getting PHN. These medications should be started as soon as possible, so you should see your doctor immediately to be evaluated for this treatment.